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<br /> NA-02622-02
<br /> Rev. �ti8�' = PERMIT APPLICATION PART A OFFICE I�SE ONLY.
<br /> �!���O4�T oF TO WORK IN PROTECTED WATERS OR WETLANDS $ P•A. N0.
<br /> �v`i�� (INCLUDIN6 DAM SAFETY) � — t° 5
<br /> NATURAL RESOURCES QSWCD OC/C
<br /> ►►Please read instructions before attemptirig to complete this application. ❑W•D• ❑USCOE
<br /> I. ApplicanYs Name (Last, First,.M.l.) Authorized Agent (if applicable) Telephone Numberaa�ea
<br /> iA ( 81P ) 9�i-3�!
<br /> Address (Street, RFD, Box Number, City, State, Zip Code)
<br /> 328 I�shlAgt� A�, Se. Ho�klns. l4�.. SS�43
<br /> Government Lot(s) Quarter Section(s) Sections(s) Township(s) Range(s) Lot, Block, Sub-Division
<br /> SE !/�t S lI7 23
<br /> Fire No., Box No. or Project Address County Project will affect Lake,Wetland or Watercourse
<br /> "��Pf� �f knownumber, t�, p�ka �7���
<br /> II. PROPOSED PROJECT III. PROJECT AREA
<br /> ❑ fill m excavate ❑ dam ❑ culvert ❑ shore-protection
<br /> ❑ drain ❑ construct ,,❑ lake ,� wetland ,� ❑ other (specify) .
<br /> ❑ remove ❑ other (specify) ❑ whart ❑ shoreline ' � �
<br /> ❑ abandon ❑ bridge ❑ obstruction
<br /> ❑ install ❑ harbor ❑ watercourse �
<br /> IV. ESTIMATED PROJECT COST ❑ riprap ❑ sand blanket
<br /> $ � channel ❑ permanent dock
<br /> V. BRIEF EXPLANATION OF PROJECT
<br /> �xea�ate �st sfde ot c�a�e1 ts r�estere �epth t� 6' metar �oreel wat� elevatfo� at'
<br /> 92l.4.
<br /> VI. JUSIIFICIITION (Explain why this project is needed)
<br /> Yest sfda of cha�ael r�s �redqed oat i�prouiaataty 8 �rears a8e. €�est si�s of ct�a��el
<br /> aa�ds to be �ged �+,
<br /> III. ENVIRONMENTAL IMPACT (Anticipated changes to the �rater and related land resources, including unavoidable but detrim�ntal effects)
<br /> �K .
<br /> Mfuor �M�le�ca d�e�tng e�cccarattas. �
<br /> ; :_-� .d�;..�. . ;w...�,,,.
<br /> III. ALTERNATIVES (Other alternatives to�the ac#ion proposed}' � ' " ' `�-� ` ` �'" � '
<br /> !1s 1�astbl� alternative; boat p�sa� vitl be rastrlcted wrder rxtstfrtg c��ltto�s.
<br /> IX. �hereby make application pursuant to Minnesota Statutes Chapter 105.42 and all supporting rules for a pe�mit to work in or affect the above named protected
<br /> water(s)in accordance with all supporting maps,plans,and other information submitted with this application.The information submitted and statements made
<br /> concerning this application are true and correct to the best of my knowledge.
<br /> ,
<br /> Signature.of(�wner or Authorized Agent � %� Date
<br /> STATE OF � /,1�
<br /> •�'-= �-�-�.X� � �. T
<br /> Signa�u o�'Leasee Date
<br /> COUNTY OF
<br /> Subscribed and sworn to me is
<br /> /��f 19 J��'�y � Distribution:
<br /> � �� �
<br /> White: DNR
<br /> , Blue: SWCD
<br /> My.commission expires • ■ Green: Watershed District
<br /> BERNICE B.IOHNSON
<br /> �.�c� NOTARY PUBLIC-MINNESOTA� � �Idenrod� Clty 0� COUllty
<br /> Signatur "�- �- � Pink: Army Corps of Engineers
<br /> ;� HENNEPIN COUNTY
<br /> � IAy Commission Expires Oct.28, 198T , Canary:Applicant
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